FEBRUARY 2015
 
 

NICHE Hospital Advances and Resources Update: Transitions 

 

Transitions can be stressful for patients, their families and caregivers. Evidence suggests that transitions are particularly susceptible to breakdowns in care and thus there is a need for transitional care services. The following is an excerpt from Lim F, Foust J, and Van Cleave J. Transitional Care. In: M Boltz, E Capezuti, T Fulmer, & D Zwicker. (eds.) Evidence-Based Geriatric Nursing Protocols for Best Practice (4th ed.). New York: Springer Publishing. 

 

Persons with continuous complex care needs frequently require care in multiple settings. The American Geriatrics Society defines transitional care as "a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location." Representative locations include (but are not limited to) hospitals, sub-acute and post-acute nursing facilities, the patient's home, primary and specialty care offices, and long term care facilities. During transitions between settings, this population is particularly vulnerable to experiencing poor care quality and problems of care fragmentation. For example, among Medicare patients, 20% were hospitalized within 30 days and 34% were re-hospitalized within 60 days (Jencks, et al. 2009). Despite how common these transitions have become, the challenges of improving care transitions have historically received little attention from policy makers, clinicians, and quality improvement entities, until recently. With hospital readmission now heralded as a quality indicator, there is more incentive to correct transition-related problems.

 

Following is an approach developed at a NICHE Hospital related to transitions and older adults. 
 
QUICK LINKS

2015 NICHE Online Connect Webinars

JOIN NICHE - Leadership Training Program Registration 

NEWS From NICHE
2015 Annual NICHE Conference
Innovation through Leadership

Book your hotel room now to receive the discounted NICHE room rate of $209 

per night! Offer good through March, 20, 2015 or until room block is sold out.

REGISTER NOW!

EVENTS: See NICHE
We've moved to:
250 Park Avenue South, 6th Flr.
New York, NY, 10003
Phone and email remain the same.

AAHPM & HPNA

 

February 25-28, 2015 Philadelphia, PA

 

ASA Aging in America Conference

 

March 23-27, 2015
Chicago, IL

 

AAGP

 

March 27-30, 2015
New Orleans, LA

 

Innovations

 

Transitioning Home Post-Hospital: Collaborative Project to Support Older Adult Transitions

 

2014 NICHE Conference Poster. Authors: Joanne Grosh, RN, MA; Lisa Senawi, RN, MSN; Andrea Gossett Zakrajsek, OTD, MS, OTRL & Elizabeth Schuster, PhD, Chelsea Community Hospital/Saint Joseph Mercy Health System and ChelseaCare Home Health.

 

These facilities formed a community research partnership to explore and support transitions of older adults through the healthcare system, specifically from a hospital stay to home with rehabilitative services. The team used a participatory action research approach that included:

  • Observation of home health sessions between service providers and older adults
  • In-depth interviews of home health service providers
  • In-depth interviews of older adults receiving home health service

Research Findings

 

Barriers to Care Transitions

  • Communication: Breakdown in information exchange between providers and patients, and among service providers
  • Challenges in Returning Home: Negotiating the physical environment in the home and community, specifically falls and giving up value-added activities

Key Supports

  • Overcoming environmental barriers (i.e. ramps, mobility devices)
  • Regaining confidence and changing perception of ability to re-enter the community
  • Family, friends, other caregivers facilitating successful transitions

 

Actions Based on Research Findings

  • System to enhance communication between service providers and older adults
  • Handouts and pamphlets to facilitate communication
  • List of useful questions for patients to ask and advice for patients regarding care transitions

View the conference poster 

 

Conference Alert!

 

Eric A. Coleman, M.D., MPH, professor of medicine and head of the division of Health Care Policy and Research at the University of Colorado Anschutz Medical Campus, will be delivering a keynote address dealing with transition models at the 2015 Annual NICHE Conference.
 
NICHE Related Resources
Full access to some of the resources referenced here is only available to NICHE member hospitals.
 
NICHE Organizational Strategies
Evidence-Based Geriatric Nursing Protocols for Best Practice Book (4th Ed.)

 

 
Geriatric Patient Care Associate (GPCA) Curriculum

 

NICHE GPCA Module Module: Partnering with Therapists

 

 
Geriatric Resource Nurse (GRN) Curriculum

 

Module: Family Caregiving

 

Spotlight on NICHE